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PubMed1988

Arthroscopic irrigation and debridement of infected total knee arthroplasty: report of two cases.

Various methods have been described for the treatment of the acutely infected total knee arthroplasty. These include antibiotic suppression, open debridement and irrigation, exchange arthroplasty, resection arthroplasty, arthrodesis, and amputation. A method not frequently reported is arthroscopic irrigation and debridement. Two cases of acutely infected total knee arthroplasty treated with arthroscopic irrigation and debridement are presented. In both cases there was a benign postoperative course averaging five months. Both infections were secondary to hematogenous seeding from a distant focus of infection. The patients presented within approximately 12 h after the onset of knee symptoms and were taken for arthroscopic irrigation and debridement within 12 h after presentation. Gram-positive organisms sensitive to the antibiotics being used were cultured in both. Postoperative knee function and range of motion returned rapidly and disability was minimal. At average 30-month follow-up both patients were pain free, had full activity of daily living, and had no clinical or radiographic evidence of infection. Arthroscopic irrigation and debridement appears to be an effective method of treatment in select cases of infected total knee arthroplasty.

Acute Disease↗
PubMed1995

Femoral head autograft in simultaneous primary and revision total hip arthroplasty.

Bilateral total hip arthroplasty during one anesthetic procedure can be beneficial in properly selected patients. For patients who have a failed hip arthroplasty requiring revision and a contralateral arthritic hip requiring primary arthroplasty, bilateral surgery permits the resected femoral head from the primary procedure to be used as a fresh autogenous bone-graft during the revision procedure. Four patients underwent combined primary hip arthroplasty and contralateral revision hip arthroplasty during one anesthetic procedure. The femoral head obtained during the primary procedure was used as a structural acetabular bone-graft in three patients, and bone slurry was used to fill cavitary acetabular defects in one patient. A femoral neck autograft was used to reconstruct a calcar defect in one of the patients. After an average follow-up period of 27 months, all hips were functioning well with healed bone-grafts and stable prosthetic components.

Acetabulum↗
PubMed1990

Treatment of infected total knee arthroplasty. Irrigation and debridement versus two-stage reimplantation.

The results of 24 cases of deep wound infection after total knee arthroplasty were reviewed. Twenty-one knees were initially treated with irrigation and debridement. Infection recurred in 15 knees. An increased infection rate occurred after irrigation and debridement in patients in whom the index prosthesis was in place more than 2 weeks. Nine knees (including 7 that had removal after irrigation and debridement) were treated with removal of the infected prosthesis, intravenous antibiotics, and delayed reimplantation. Immediate exchange was done in one knee. There were no recurrences in this group (P less than .001). The final status of the patients included 8 with fusions or resection arthroplasties and 16 with a prosthesis. The average Hospital for Special Surgery knee rating was 41 in patients without a prosthesis and 75 in patients with a prosthesis (P less than .001). The authors conclude that irrigation and debridement is not likely to be successful for treatment of infections when used more than 2 weeks after the initial arthroplasty. Also, two-stage reimplantation for the treatment of infected total knee arthroplasties gives a reliably low recurrence rate and provides a superior clinical result, compared to arthrodesis or resection arthroplasty.

Debridement↗
PubMed1992

The effect of preoperative knee deformity on the initial results of cruciate-retaining total knee arthroplasty.

Between November 1985 and June 1987, 751 posterior cruciate-sparing total knee arthroplasties were performed on 523 patients who exhibited fixed varus or valgus deformities. Patients excluded from this study included the following: those with a postoperative follow-up period of less than 2 years (including patients who had died), patients who became infected, and patients with previous failed total knee arthroplasty in the same knee. A total of 473 knees left for evaluation. All arthroplasties were measured using anatomic axis for alignment measurement. The Hospital for Special Surgery scoring system was used to determine the clinical scores prior to the end of each follow-up examination. All ligament releases were performed sequentially, including balancing of the posterior cruciate ligament. All arthroplasties were divided into six separate groups depending upon the degree of varus or valgus deformity. Kaplan-Meier curves were constructed using three methods of failure definition. Curves were then compared between groups. The mean Hospital for Special Surgery score was no different between any of the groups, except for the group of 6 degrees-10 degrees varus, which was significantly higher than the mean score of the 11 degrees and higher valgus group. All other groups were the same statistically. It is concluded that severe varus and valgus deformities may be satisfactorily corrected with the use of a cruciate-retaining type of total knee arthroplasty.

Adult↗
PubMed1988

Posterior cruciate ligament balancing during total knee arthroplasty.

This study was undertaken to describe and evaluate the use of a posterior cruciate ligament balancing technique in total knee arthroplasty. Two hundred sixty total knee arthroplasties in 156 patients were performed between January 1984 and December 1985 using the described technique of posterior cruciate ligament balancing when necessary. Seventy-eight arthroplasties (30%) required ligament balancing to obtain a smooth flexion arc. At 1-year minimum follow-up evaluation, no knee was found to be unstable in the anterior-posterior plane. Average flexion arc for the posterior cruciate ligament balanced knees was 2 degrees - 114 degrees and for the standard arthroplasty was 2 degrees - 107 degrees. Posterior cruciate ligament balancing is a useful adjunct in total knee arthroplasty surgery when flexion gap tightness occurs.

Humans↗
PubMed1989

Stress distribution in the ulna following a hinged elbow arthroplasty. A finite element analysis.

The failure rates for total elbow arthroplasty, in comparison to those for hip arthroplasty, are quite high, and a precise understanding of the underlying causes still remains elusive. The presence of abnormal stresses is a known factor that accelerates loosening of hip and knee arthroplasties. Although a large number of biomechanical studies have led to a better understanding of elbow joint kinetics, very little is known about the stress distribution in this joint. The implantation of a Coonrad humeral component increases stresses in the bone and cement adjacent to the stem tip and hinge regions. An analysis of implanted ulnar stresses and a comparison of those stresses to implanted humeral stresses would improve our understanding of hinged elbow arthroplasty. For this reason, the distribution of mechanical stresses in the ulna are investigated in this study. Using a specially developed casting and sectioning technique, three-dimensional finite element meshes were obtained from an intact human cadaver ulna and an ulna fitted with a Coonrad prosthesis. The material properties were derived from values presented in the literature. Stress distributions in response to axial compression, axial torque, and anteroposterior (AP) force were computed. The cancellous bone and cement regions adjacent to the stem tip of the prosthesis exhibited higher stresses than those in the same regions of the intact case. The higher stresses in the ulna with an implanted prosthesis, as compared to the intact model, might initiate loosening or failure of the prosthesis. The stresses in the cortical bone region adjacent to the prosthesis head were decreased. This is consistent with the clinical observations of bone atrophy following total elbow arthroplasty.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1996

Mycobacterium chelonae infection following a total knee arthroplasty.

Infection following total knee arthroplasty is a major cause of implant failure, with an incidence of infections between 1 and 12%. Although there have been no previously reported cases of infection with Mycobacterium chelonae following total knee arthroplasty, this mycobacterium appears to be a potential pathogen in arthroplasty. When infection following total knee arthroplasty is evident but standard cultures come back negative, atypical mycobacterium infection should be considered. Mycobacterium chelonae does not grow in the normally allotted culture time, so false negative results are common. Once identified, M. chelonae is difficult to treat because of its resistance to standard drug therapies. Details of the first reported successful diagnosis and treatment of an infection with M. chelonae following a total knee arthroplasty are reported.

Aged↗
PubMed1997

Postoperative blood salvage and reinfusion after total joint arthroplasty.

The purpose of this prospective study was to evaluate the safety of salvage and reinfusion of postoperative sanguineous wound drainage using the ConstaVac Blood Conservation System (Stryker, Kalamazoo, MI). A prospective analysis of 135 primary total hip and total knee arthroplasties was carried out. The collection time for reinfusion was limited to 6 hours, and suction pressure was kept to a minimum by using the lowest setting on the device. For all patients, no citrate-phosphate-dextrose anticoagulant was added to the reservoir. To evaluate the effect of reinfusion on hemostasis and the blood coagulation system, antithrombin III, fibrinogen, and D-dimer levels of 40 of 135 patients were measured before surgery and on the first and seventh days after the operation. The mean volume of reinfusion of postoperative drainage was 437 mL for the patients with total hip arthroplasties, 883 mL for those with total knee arthroplasties, and 1,713 mL for those with bilateral total knee arthroplasties. Ninety-nine of 135 patients underwent operations without homologous blood replacement. Transient chills with mild fever were seen in 2 patients during reinfusion. No complications related to air embolism, coagulopathy, renal failure, or sepsis were recognized in any of the patients. This study suggests that postoperative blood salvage and reinfusion appear to be safe and effective in patients undergoing primary total hip and knee arthroplasties.

Adult↗
PubMed2003

[Total shoulder arthroplasty vs. hemiarthroplasty].

Shoulder arthroplasty remains problematic despite the dramatic development of the new implant systems, due to the anatomical characteristics of the shoulder joint. The development of the modern third and fourth generation of shoulder prostheses enables the surgeon by its the three dimensional modularity to adjust the inclination and dorsomedial offset and to reconstruct the anatomic center of rotation. The fixation of the glenoid component is one of the most complicated aspects in the total shoulder arthroplasty. The main criteria regarding hemi- or total arthroplasty are based on morphological changes in the glenoid, the condition of the rotator cuff muscles, disorder etiology, age and activity level of the patient. The cup arthroplasty has proven itself as an alternative to standard humeral shaft arthroplasty. The main advantages of this new system are the elimination of the obligatory humeral head resection and the possibility of converting to the classical humeral shaft prosthesis method. First experiences with the cup system have been evaluated in the department of accident and reconstructive surgery of the UKBF in Berlin as part of a clinical trial. Between March 1998 and June 1999 15 shoulder prostheses in 14 patients were implanted in this hospital. The implants were inserted 8 times in a rheumatic shoulder, 4 times in posttraumatic arthrosis and in 3 humeral head necroses. 13 patients with 14 prostheses were available for follow up. An improvement from 23 to 55 average score points (Constant-Score) was attained by implantation of the cup system within a mean postoperative observation period of 6.1 months.

Arthritis, Rheumatoid↗
PubMed1992

Perioperative factors associated with septic arthritis after arthroplasty. Prospective multicenter study of 362 knee and 2,651 hip operations.

Perioperative factors associated with late septic arthritis after knee and hip arthroplasties were prospectively investigated. All patients received a short course of perioperative cefuroxime. After a follow-up of 1 year, septic arthritis was diagnosed in 9/362 patients (2.5 percent) after knee arthroplasty and in 17/2651 patients (0.64 percent) after hip arthroplasty. For the knee, factors associated with septic arthritis after arthroplasty were rheumatoid arthritis, wound infection, an unhealed wound, and a painful, limited knee function at discharge from the hospital. For the hip, corresponding risk factors were diabetes, failed fracture osteosynthesis, a breakdown of sterility during operation, wound infection, postoperative urinary tract infection, and an unhealed wound at discharge from the hospital or a difficult rehabilitation course. Reoperation after knee and hip arthroplasty was also clearly associated with a higher incidence of septic arthritis.

Arthritis, Infectious↗
PubMed1990

Risk factors for wound infections after total knee arthroplasty.

Wound infections are an infrequent but serious complication of total knee arthroplasty. Between January 1984 and November 1987, 20 of 243 (8.2%) patients at two affiliated hospitals developed surgical wound infections following 259 total knee arthroplasty procedures performed in clean-air operating rooms. Eighteen (90%) of the patients had deep infections; nine required removal of the prosthesis. A single surgeon (surgeon X) was associated with 18 of the procedures that had subsequent infection (risk ratio (RR) = 9.4, 95% confidence interval (CI) 2.2-39), and an investigation was carried out in an effort to explain the difference in infection rates between surgeon X and other surgeons. In a cohort study, stratified analyses identified a preoperative American Society of Anesthesiologists (ASA) physical status class greater than or equal to 3, surgeon X, and early postoperative use of a continuous passive motion device as risk factors associated with surgical wound infection following total knee arthroplasty procedures. Logistic regression analyses identified being a patient operated on by surgeon X with an ASA class greater than or equal to 3 as the only significant independent risk factor for total knee arthroplasty-associated surgical wound infections (RR = 9.3, 95% CI 2.8-31). The effect due to surgeon X could not be explained by receipt or timeliness of administration of antimicrobial prophylaxis, type of prosthesis inserted, duration of operation, postoperative use of continuous passive motion, or underlying etiology of joint disease. The authors conclude that surgical technique and patient's severity of illness were the primary determinants of surgical wound infection after total knee arthroplasty. This study demonstrates the complexity of epidemiologic investigation of surgical wound infections and the importance of considering patient severity of illness when interpreting surgeon-specific infection rates.

Cohort Studies↗
PubMed1996

Quantitative scintigraphic evaluation of total knee arthroplasties: a feasibility study.

For the development and validation of a quantitative approach to the analysis of bone scans after total knee arthroplasty, 39 consecutive patients with 40 prostheses (6 males, 33 females; mean age, 70 years) were scheduled for clinical, radiographic, and scintigraphic examination ranging from 9 to 90 months after surgery. Twenty-seven total knee arthroplasties were considered to be asymptomatic and 13 symptomatic according to the clinical and radiographic findings. Significant differences were found for 99mTc-methylene diphosphonate uptake for femur and tibia and between symptomatic and asymptomatic patients. A reference range was determined for radionuclide uptake in the periprosthetic bone of the 27 asymptomatic total knee arthroplasties; this range was then used to identify loose total knee arthroplasties among the 13 symptomatic knees. With a clinical and radiographic followup performed 1 year after scintigraphy as a standard of comparison, a sensitivity of 88% (7/8) and a specificity of 100% (5/5) was demonstrated. These preliminary results suggest the feasibility of a quantitative approach to the scintigraphic evaluation of total knee arthroplasties after the first postsurgical year.

Aged↗
PubMed2000

Assessment of patient selection criteria for treatment of the infected hip arthroplasty.

In a group of 37 infected hip arthroplasties (36 patients) treated consecutively between January 1997 and October 1999, the feasibility of published patient selection criteria for direct exchange arthroplasty was tested. These criteria include the requirement of a healthy patient with good soft tissues, minimal femoral bone loss, and an organism identified preoperatively as an antibiotic sensitive gram-positive organism. After assignment of the selection criteria, only four patients (four hips) (11%) were deemed potential candidates for a direct exchange procedure. Infected arthroplasties excluded from a primary exchange included 14 patients (15 hips) with gram-negative or methicillin-resistant gram-positive organisms obtained from preoperative joint aspirations, 10 patients (10 hips) with moderate or severe femoral bone loss, four patients (four hips) who required a proximal femoral osteotomy for component removal, two patients (two hips) with poor health status, and two patients (two hips) with poor soft tissues. Because of the increasing emergence of antibiotic-resistant bacteria and an increased prevalence of revision arthroplasties with associated bone loss, the feasibility of published selection criteria for direct exchange are limited. A philosophy of delayed reconstruction for the treatment of the infected hip arthroplasty seems most appropriate in the current era of patient treatment.

Acetabulum↗
PubMed2004

Total wrist arthroplasty.

Normal wrist motion is accomplished by a complex interaction of multiple articulations involving the radius, ulna, and carpal bones. Total wrist arthroplasty cannot duplicate this intricate system, but it can potentially produce a stable, pain-free joint with functional range of motion. Achieving a functional and durable outcome requires proper patient selection, careful preoperative planning, and accurate implantation. Because arthroplasty poses greater risks than arthrodesis, low demand patients with special needs or desires for wrist motion are the best candidates. In particular, patients with arthritis involving multiple joints of the upper limbs often find tasks of daily living easier when some wrist motion is preserved. Other patients may choose arthroplasty over arthrodesis to better maintain their ability to perform vocational and avocational activities. Regardless of a patient's desire for arthroplasty, he or she must accept the lifetime of restricted activities imposed by an artificial wrist, which are similar to any other joint replacement. Complications may include infection, imbalance, implant breakage, dislocation, and loosening. Revision arthroplasty or conversion to an arthrodesis are options for the failed total wrist.

Journal Article↗
PubMed2006

Thumb trapeziometacarpal arthritis: treatment with ligament reconstruction tendon interposition arthroplasty.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the pathomechanical and biochemical basis for thumb trapeziometacarpal joint degeneration. 2. Diagnose and grade trapeziometacarpal joint disease based on presentation, physical examination (including provocative testing), and radiographic evidence. 3. Understand the principles of ligament reconstruction and tendon arthroplasty procedures. 4. Describe the surgical technique for ligament reconstruction tendon interposition arthroplasty and its variants. BACKGROUND: Osteoarthritis of the trapeziometacarpal joint is the second most common site of degenerative joint disease in the hand, and mostly affects postmenopausal women. Degenerative arthritis of the thumb trapeziometacarpal joint is associated with a lack of bony constraints and laxity of the supporting ligaments, particularly the anterior oblique ("beak") ligament, which is consistently implicated in disease progression. Resultant increases in joint stress loads leads eventually to metacarpal and trapezial articular destruction, thumb instability, and pain. METHODS: In this article, the authors review the diagnosis and treatment modalities available to the surgeon in the treatment of patients with trapeziometacarpal osteoarthritis. The technique of ligament reconstruction tendon interposition arthroplasty is discussed in detail. RESULTS: Ligament reconstruction tendon interposition arthroplasty procedures center on three common principles: (1) excision of the diseased trapezium; (2) reconstruction of the beak ligament; and (3) interposition of a tissue substance to maintain metacarpal position. CONCLUSIONS: Both conservative and surgical management can be effective in the treatment of trapeziometacarpal arthritis, when properly selected. The success of ligament reconstruction tendon interposition arthroplasty in treating trapeziometacarpal arthritis has withstood the test of time.

Anti-Inflammatory Agents, Non-Steroidal↗
PubMed1994

Osteonecrosis of the femoral head treated with total hip arthroplasty without cement.

With use of porous-coated implants, total hip arthroplasty was performed in a consecutive series of thirty patients (thirty-five hips) who had a preoperative diagnosis of late-stage (Ficat and Arlet stage-III or IV) osteonecrosis of the femoral head. The patients were evaluated clinically and radiographically, and the data were recorded in a prospective manner. The average duration of follow-up was seven and one-half years (range, five to ten years). The average age of the patients at the time of the operation was thirty-two years (range, twenty-one to forty years). Signs of osseointegration of the femoral stem to the host bone were demonstrated in thirty-three hips (94 per cent). In the porous-coated hemispherical acetabular cups of these hips, an optimum bone-implant interface was identified and maintained, suggesting bone ingrowth. The rate of revision was 3 per cent (one hip) for the femoral side and 6 per cent (two hips) for the acetabular side, for an over-all rate of 6 per cent. All patients maintained a high level of activity postoperatively. There was moderate or severe remodeling of proximal femoral resorptive bone and stress-shielding in six hips (17 per cent) and osteolytic reactions in six hips. Complications were frequent (six hips) and included one deep infection; two dislocations; two instances of heterotopic ossification; and one fracture of the calcar femorale, which occurred intraoperatively. The thirty patients had a lower rate of revision and improved clinical outcomes compared with other reported series of young patients managed with total hip arthroplasty with cement who had the same diagnosis and similar postoperative follow-up. However, the latter series involved implants of an earlier design that had been inserted with older techniques of cementing. When arthroplasty is considered for the treatment of late-stage osteonecrosis of the femoral head in young patients, the use of total hip implants without cement that allow for bone ingrowth appears to be a viable alternative to arthroplasty with use of cement. However, longer follow-up is needed to determine the outcome of the osteolytic reactions that we observed. We therefore recommend this procedure with some caution because of the high rate of complications and the potential for failure of the arthroplasty related to the osteolytic reactions.

Activities of Daily Living↗
PubMed1994

The hospital cost and the cost of the implant for total knee arthroplasty. A comparison between 1983 and 1991 for one hospital.

The hospital cost of total knee arthroplasty at the Lahey Clinic was evaluated by a comparison of the data for twenty-eight patients who had had the operation in 1983 with the data for forty-two patients who had had the same operation in 1991. The hospital bills were analyzed for each patient. Each hospital charge was converted to cost with the use of government-mandated hospital-specific cost-to-charge ratios. The average actual hospital cost for total knee arthroplasty increased 17 per cent, from $10,122 in 1983 to $11,826 in 1991. However, in inflation-adjusted dollars, the hospital cost for total knee arthroplasty decreased 15 per cent during this period. When the costs for total knee arthroplasty in 1983 and 1991 were allocated to various service centers in the hospital, the cost for a hospital room was found to have decreased from 47 per cent of the hospital cost in 1983 to 31 per cent of that in 1991. The cost of a hospital room decreased 23 per cent in actual dollars and 46 per cent in inflation-adjusted dollars during this period. In sharp contrast, the cost of a knee implant increased from 13 per cent of the hospital cost for total knee arthroplasty in 1983 to 25 per cent of that in 1991. The average cost of the prosthesis increased from $1359 in 1983 to $2960 in 1991. This represents a 118 per cent increase in actual dollars. The inflation-adjusted increase in the cost of the implant was 59 per cent.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1994

Intramedullary arthrodesis of the knee after failed total knee arthroplasty.

Eighteen patients (eighteen knees) were managed with an intramedullary arthrodesis after a failed total knee arthroplasty. Twelve knees had had a revision total knee arthroplasty and six, a primary total knee arthroplasty. Three knees had had failure of a hinged prosthesis. In eleven knees, the arthroplasty had failed because of infection. Nine patients had had previous attempts at arthrodesis with external fixation. The average duration of the operation was six hours, and the average blood replacement was 2975 milliliters. A vascularized fibular pedicle graft was used in four patients. At a mean of thirty-seven months after the arthrodesis, sixteen of the eighteen patients had a complete radiographic union. The mean time to union was 5.5 months. Although a high rate of union was achieved in these patients, complications occurred in ten of the eighteen knees and this must be considered. Intramedullary arthrodesis is a successful method of salvage for a failed total knee arthroplasty or one complicated by infection that is not amenable to revision, but it is technically demanding and has frequent complications.

Adult↗